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POLICY TITLE: Facility Licensing CHAPTER:

PAGE 1 OF 23

CHILD AND FAMILY SERVICES AGENCY

PROFESSIONAL STANDARDS

EFFECTIVE DATE:

LATEST REVISION: September 27, 2010

REVIEW BY LEGAL COUNSEL: September 2, 2010

I. AUTHORITY

All applicable federal and District of Columbia laws, rules and rules, including the Prevention of Child Abuse and Neglect Act of 1977, DC Law 2-22 (eff. September 23, 1977), as amended by the Adoption and Safe Families Act of 2000; Law 13-136 (eff. June 27, 2000), and the Child and Family Services Agency Establishment amendment Act of 2000; Law 13-277 (eff. April 4, 2001); 42 USC Ch. 7 (the Social Security Act), Titles IV-B and IV-E; the LaShawn Modified Final Order (November 18, 1983); the LaShawn Implementation Plan (April, 2002), and 29 DCMR Chapters 62 and 63.

II. APPLICABILITY This policy applies to Child and Family Services Agency (CFSA or Agency) employees, CFSA-contracted agency personnel, and persons interested in operating a youth residential facility (YRF) or independent living program (ILP) that services the youth in the District of Columbia.

III. RATIONALE When parents are unable or unwilling to keep children safe, CFSA [with court approval] must remove the children from the home. Licensing of group care settings by CFSA is a quality control process that ensures the safety and well-being of children and youth in placement by enforcing regulatory compliance. The following policy is designed to establish the procedures for licensing group care facilities as well as taking adverse licensing action against a facility for non-compliance of District law and CFSA Policy.

IV. POLICY It is the policy of CFSA to set forth standard procedures and guidelines for persons interested in providing care to children and youth to ensure their safety and well-being. To this end, CFSA requires persons interested in operating a youth residential facility (YRF) or an independent living program (ILP) in the District of Columbia, except for facilities intended primarily for detained or delinquent youth or persons in need of supervision (PINS) to apply for a license with CFSA’s Office of Facility Licensing (OFL). The applicant may go to CFSA’s website at www.cfsa.dc.gov or contact OFL at 202-724-7633 to obtain information regarding the licensing process.

Approved by:__________________________ Signature of Agency Director

http://www.cfsa.dc.gov/

POLICY NUMBER/TITLE CHAPTER NUMBER/TITLE PAGE NUMBER

Facility Licensing of 23

Persons who operate facilities outside the District of Columbia and who are interested in providing services to District of Columbia youth must possess a valid license to service youth from the appropriate licensing entity in the jurisdiction in which the facility is operating.

Upon receipt of a license to operate a YRF or ILP, it is the responsibility of the licensee to ensure that they employ policies and procedures that comport with District and federal law, as well as the laws set forth in their own jurisdiction. The licensee shall also ensure the permanency, safety, and well-being of every youth placed in its care.

V. CONTENTS A. Requirements to Obtain an Original Annual License to Operate a YRF or ILP

B. Annual Licensure (Renewal of License) C. The On-Site Inspection for License Renewals D. Deficiencies Identified During License Renewals E. Health and Safety Concerns F. License Modification G. Considerations for Facilities Located Outside the District of Columbia. H. Handling Complaints and Allegations of Rule Violations I. Suspension and Revocation of a License J. Provisional Licenses K. Restricted Licenses L. Appeals of an Adverse Licensing Action M. Variances N. Unusual Incidents O. Institutional Investigations

VI. ATTACHMENTS A. Definitions B. Intent to Seek Licensure Form C. Record Index Form D. Environmental and Sanitation Inspection Checklist E. Notification of Intent to Renew Licensure F. How to Prepare for an On-Site Inspection Form G. Request for Modification Form H. Sanitation Inspection Request Letter

VII. PROCEDURES Procedure A: Requirements to Obtain an Original Annual License to Operate a YRF or ILP

OFL shall issue a license to operate a YRF or ILP upon the applicant’s successful completion of a three-step licensing process: Phase I – Completion of the Pre-licensing Workshop and Submittal of the Application and Supporting Documents, Phase II - The Sanitation and Environmental Inspection (i.e., Physical Plant Inspection), and Phase III – Final Walk- Through and License Issuance. The licensing specialist and/or sanitarian provide support and technical assistance to help guide the licensee or applicant through the licensing process.



Phase I- Completion of Pre-licensing Workshop and Timely Submittal of the Application and Supporting Documents 1. To obtain an original annual license to operate a YRF or ILP, the

applicant must contact OFL and register to attend a pre-licensing workshop entitled: Orientation to Facility Licensing in the District of Columbia.

a. The pre-licensing workshop explains the licensing requirements and process, including the steps needed to obtain a license.

b. The pre-licensing workshop provides an opportunity for applicants to meet the OFL staff.

c. The application, appropriate forms, and applicable rules are distributed at the workshop.

d. The pre-licensing workshop is held on a quarterly basis.

Note: current licensees interested in seeking licensure for a type of facility they do not currently operate are required to attend the pre-licensing workshop.

2. Upon completion of the workshop, the applicant receives a Workshop Certificate of Completion. The certificate expires within 1 year from the date of receipt.

3. If the applicant remains interested in obtaining a license within 1 year from receiving the Workshop Certificate of Completion, the applicant shall sign and submit an “Intent to Seek Licensure Form” (See Attachment B) to OFL. The form shall be submitted at the address indicated on the form.

4. A completed application (with all supporting documents, hereinafter “application”) shall be submitted to OFL within 1 year from receipt of the Workshop Certificate of Completion.

a. The application shall be submitted in a tabbed binder in the order prescribed by the Record Index Form (Attachment C) and shall include all attachments.

b. If a completed application is not submitted within the 1-year time frame, then the applicant will have to attend another pre-licensing workshop before submitting an application.

5. Upon receipt of the application, the licensing supervisor, cost/price analyst and the licensing specialist review the application and all supporting documents to ensure compliance with federal and District law, and OFL policy.

Note: OFL staff shall not complete any part of an applicant’s or licensee’s application documents.



6. The licensing supervisor makes the final determination as to whether the applicant satisfied the licensing criteria.

7. Within 60 calendar days of receipt of an application, OFL shall provide the applicant with notification of the acceptance or denial of the application.

8. If the application is denied, the following tasks are completed:

a. The licensing supervisor sends the applicant a Denial Letter via email within 3 business days of the denial. The Denial Letter shall state the reason for the denial and contain information regarding the right to appeal the decision.

b. The licensing assistant shall also send the Denial Letter via mail, fax, or email within 2 business days to the applicant informing him or her of the denial and the need to retrieve the application binder. The licensing assistant shall document in the database the date the notice of the denial was sent.

c. The applicant shall have 5 business days to retrieve an application that is denied from OFL before it is destroyed.

d. The applicant may re-submit the application if it will be received within 1 year of being issued the Workshop Certificate of Completion.

e. If the 1-year time frame for submittal expires, the applicant must attend another pre-licensing workshop before submitting another application.

9. The following factors may lead to the denial of an application for an original annual license to operate a YRF or ILP:

a. A completed application was not submitted within the 1-year time frame from the receipt of a workshop certificate of completion.

b. OFL’s evaluation of the application reveals that the applicant knowingly reported false information.

c. The applicant hinders OFL or the Agency from completing the application or process (i.e., failure to provide OFL with additional information/documents upon request).

d. A previous license or renewal was denied or revoked by CFSA in the past.

e. The applicant cannot provide for the health, safety, and welfare of the youth in its care. The following factors may be considered when making this determination:

i. The applicant or physical plant violates or fails to comply with any provision of the applicable regulations.



ii. The applicant has a history of regulatory violations, which demonstrates an inability to provide for the health and safety of children and fails to provide adequate safeguards to ensure that similar violations will not occur.

iii. The applicant has a history of abuse of alcohol or other controlled dangerous substances, mental instability, or ongoing health problems, which are revealed through the inspection interview process or clearances.

f. CFSA may deny an application for a license for any other good cause.

10. If the application is accepted, the licensing supervisor forwards the applicant an Acceptance of Original Application Letter along with an Environmental and Sanitation Inspection Checklist (Attachment D). The Letter shall inform the applicant of the successful completion of Phase I. He or she may proceed to Phase II – The Sanitation and Environmental Inspection.

11. A determination regarding whether to grant the applicant a license shall be made within 90 days for a YRF, and within 60 days for an ILP from the time OFL receives a complete application with all supporting documents.

Phase II- Sanitation and Environmental On-Site Inspection (Physical Plant Inspection)

1. Within 3 business days of the applicant’s successful completion of Phase I, the licensing specialist shall send a memo via email to the sanitarian to request a physical plant inspection.

2. Within 5 business days from the receipt of the memo, the sanitarian shall contact the applicant via email or telephone to schedule an appointment for the inspection of the physical plant.

a. The physical plant inspection shall occur within 10 business days from the date the sanitarian contacts the applicant.

b. The sanitarian shall e-mail the applicant to confirm the appointment.

c. The sanitarian shall encourage the applicant to conduct a self-inspection using the Environmental and Sanitation Inspection Checklist (Attachment D).

3. The program administrator and the primary staff member(s) responsible for the facility’s daily operations shall be physically present at the time of the inspection.

4. The sanitarian documents any findings in the physical plant on the Environmental Inspection Checklist. The sanitarian shall informally discuss any findings with the applicant and with the assigned licensing specialist (if in attendance) at the site once the inspection is complete.



5. The sanitarian shall confer with his or her supervisor regarding all observations identified on the Environmental Inspection Checklist.

6. The sanitarian shall complete the Physical Plant Section of the Licensing Report of Findings (ROF) and ensure that the information listed in this section includes all of the following information:

a. The findings listed in the Environmental Inspection Matrix

b. Any recommendations made by the Licensing Supervisor

c. Any identified Corrective Action Plan (CAP) needed to ameliorate any deficiencies

7. The OFL program manager, licensing supervisor, licensing specialist, and sanitarian all review, approve, and sign the ROF.

8. Once the ROF is reviewed, approved, and signed by the above-listed parties, the sanitarian shall email a copy of the ROF to the applicant, and then mail the original copy containing the required signatures.

9. If the ROF contained a CAP, the applicant shall be granted two opportunities to submit his or her plans to ameliorate the deficiencies. The plans shall be emailed to the sanitarian.

a. The applicant has 48 hours to submit the plans to ameliorate the initial CAP within 3 business days of receipt of the ROF.

b. If the CAP is not accepted, the applicant shall have an additional 24 hours to resubmit plans to correct the CAP.

c. If the CAP is still not accepted, the application shall be denied.

i. The sanitarian shall forward a copy of the Denial Letter to the supervisor, program manager, and deputy director for review and signature within 2 business days of issuing a denial.

ii. Upon receipt of the “signed” Denial Letter, the sanitarian shall immediately mail the “signed” copy to the applicant.

Note: When a licensee has multiple findings, the licensing specialist shall provide technical assistance to the licensee to assist with coming into compliance. Examples of technical assistance include but are not limited to meeting with staff or the program administrator to explain one or more rules in detail, providing examples of compliance, or brainstorming about a specific issue.

10. If the CAP is accepted, the applicant shall have 5 business days from the CAP due date to have all outstanding items corrected.

a. The sanitarian shall date-stamp the approved CAP upon receipt and provide a copy to the assigned licensing specialist.



b. The sanitarian shall set a date with the applicant for re-inspection within 5 to 10 business days of the CAP due date in order to confirm completion of the CAP, at a time consistent with the time-frame indicated in the CAP.

c. If during re-inspection, the sanitarian determines that the deficiencies have been ameliorated, the sanitarian shall provide the applicant with a Notice of Application Status (NAS), informing the applicant of his or her successful completion of Phase II and that he or she may proceed to Phase III- The Final Walk-Through. A copy of the NAS shall be forwarded to the licensing supervisor and program manager.

d. If during re-inspection, the sanitarian determines that the deficiencies have not been ameliorated, the sanitarian shall provide the applicant with a Denial Letter indicating that the application is denied and the applicant will be required to re-submit an original application.

i. The sanitarian shall forward a copy of the Denial Letter to the supervisor, program manager, and deputy director for review and signature within 2 business days of issuing a denial.

ii. Upon receipt of the “signed” Denial Letter, the sanitarian shall immediately mail the “signed” copy to the applicant.

11. If the ROF did not contain a CAP, the sanitarian shall send a NAS to the applicant informing him or her of the successful completion of Phase II and that they may proceed to Phase III: The Final Walk-Through and Issuance of a License. The sanitarian shall notify the licensing specialist of the successful completion of Phase II via email within 2 business days of issuing the NAS.

Phase III- Final Walk-Through and Issuance of a License

The sanitarian and licensing specialist shall conduct a final walk-through of the facility within 5 -7 business days of the applicant’s completion of Phase II.

1. The final walk-through shall consist of the sanitarian and licensing specialist conducting an inspection to ensure that the facility is prepared for the issuance of a license.

a. The licensing specialist shall ensure that no changes have occurred programmatically with the physical plant and that the facility is ready for placements.

b. The sanitarian shall ensure that the facility is equipped to meet the needs of the youth and complies with District and federal statutes and regulations.

2. The OFL shall hold a “partnership meeting” with the licensee to present the original annual license and discuss next steps and on-going requirements to maintain an annual license. CFSA’s Contracting and Procurement Administration, and the Placement Services Administration staff shall participate when appropriate.



Procedure B: Annual Licensure (Renewal of License)

Within 120 days prior to the expiration of a license, the licensing assistant shall send a Notification of Intent to Renew Licensure (Attachment E) letter to a licensed agency requesting that OFL be notified of its intent to renew its license.

1. Within 15 business days from the time of receipt, the licensing specialist reviews the application and determine whether it is sufficient and in compliance with standards, and makes a recommendation whether to accept or deny the application. If the licensing specialist determines that the application is incomplete, the licensing specialist shall issue a NAS notifying the licensee of the incomplete application.

Note: an application is deemed incomplete if it is missing those items listed on the Record Index Form (Attachment C).

2. The NAS shall include the following information and notifications:

a. The date of the receipt of the application.

b. Missing materials must be submitted within 10 business days from the date of the notice.

c. Incomplete applications may result in the licensee being placed on a closed admission status for the remainder of the current license.

d. Failure to submit an application at least 2 months prior to the expiration of the current license may result in a closed admission status.

3. If an application is submitted less than 2 months prior to the expiration of the current license, the aforementioned timeframes do not apply. Late submission may result in additional licensing actions.

4. If OFL is unable to award an annual license due to the failure of the licensee to timely submit a complete application, or if the licensee fails to be incompliance with DC or federal law or OFL policy within the time prescribed, the facility shall become unlicensed and all children residing within the facility will be required to be removed immediately.

Note: If adverse licensing actions are being considered, OFL shall inform the appropriate deputies and administrators of affected CFSA administrations, e.g., the Contracting and Procurement Administration (CPA), Contract Monitoring and Performance Improvement Administration (CMPIA), and Placement Services Administration (PSA). Depending on the nature of the findings, OFL shall formulate a plan of action in collaboration with the other affected administrations as well.

5. Within 5 business days of determining that the application is complete, the licensing specialist shall send out the annual re-licensure schedule to the licensee outlining the dates of inspection. The licensing specialist shall include the How to Prepare for an On-Site Inspection Form (Attachment F).



6. Generally, the on-site inspection should be scheduled to allow the participation of both the licensing specialist and sanitarian on the initial day of the inspection. The inspection should be scheduled at least 2 weeks from the determination of a completed application in order to improve the likelihood that key staff will be able to participate in the inspection.

Procedure C: The On-Site Inspection For License Renewals

Whenever possible, the records review and the Sanitation and Environmental On-Site Inspection shall be scheduled simultaneously in order to enable the licensing specialist and the sanitarian to work collectively in identifying deficiencies. The primary staff members responsible for the facility’s daily operations shall be present as well. All facilities require a Sanitation and Environmental On-Site Inspection. For facilities or programs with “scattered sites”, the licensing specialist may elect to participate in a sample or segment of the physical plant inspection.

1. The licensing specialist and sanitarian shall have a renewal entrance and exit conference with the program administrator, lead social worker and/or program staff who are in charge of the facility’s compliance and spectrum of services.

2. Following the Sanitation and Environmental On-Site Inspection, the sanitarian shall document any findings in the physical plant on the Environmental Inspection Checklist and before departing, provide all preliminary findings to the licensee and assigned licensing specialist, if in attendance. The licensee shall sign the sanitarian’s copy of the Environmental Inspection Checklist. The findings shall be identified according to priority, and as it relates to safety. (See Procedure E: Health and Safety Issues below for more information.)

3. All parties shall set a date for re-inspection within an agreed-upon time period based on the severity of any issues identified in the Environmental Inspection Checklist. If a date cannot be established because of the nature of the required repairs, the facility representative and the sanitarian shall agree upon a date by which the licensee shall contact the sanitarian to schedule the re-inspection, and document that date on the copy of the checklist.

4. The licensing specialist shall complete the records review portion of the inspection. The licensing specialist may work as a team with other licensing specialists, professional CFSA staff, or other District staff (e.g., nurses and educational specialists).



5. After the renewal entrance conference, the licensing specialist shall review the records of any personnel hired or promoted during the most recent licensing period, personnel records for staff hired prior to the most recent licensing period for training and other regulatory requirements, youth currently residing in the facility, or discharged youth residing in the facility within the most recent licensing period.

a. The licensing specialist may ask the designated staff to pull records.

b. Neither the sample size nor the records selected shall be shared with the facility in advance of the record review.

c. The licensing specialist shall review each record using the appropriate checklist (staff and youth checklists) and note any missing or incomplete information on the forms provided for this purpose.

d. If the licensing specialist is unable to complete the review within 1 day, he or she shall inform the designated staff when he or she shall return to continue the records review.

6. The licensing specialist shall select current residents to interview.

a. The licensing specialist shall make arrangements with the designated staff assisting with the onsite inspection to interview the youth.

b. Arrangements for interviews should allow for privacy during the interview. Interviews shall be documented on the resident interview form.

7. When conducting record checks for staff, the licensing specialist shall also select a range of staff to interview.

a. The licensing specialist shall make arrangements with the designated staff assisting with the on-site inspection to interview the staff. The staff interview is designed to determine staff’s knowledge and licensee compliance with the rules.

b. Each interview shall include a common set of general questions, and shall also include questions based upon the other findings of the inspection.

8. Any concerns arising out of the interviews shall be documented on the appropriate interview forms.

a. The licensee may be cited on the ROF as a result of the interviews if sufficient corroborating evidence of a rule violation is identified.

b. If any deficiencies are noted during the interviews, the licensing specialist may interview additional staff or youth to confirm the information.



9. At the end of each case record review day, the licensing specialist shall informally discuss the preliminary findings with the licensee’s designated staff.

Note: during this informal meeting, the licensing specialist may request and/or accept missing information identified during the record review.

10. At the end of the on-site renewal inspection, the licensing specialist and sanitarian shall have an Exit Conference with the program administrator, lead social worker and/or program staff who are in charge of the facility’s compliance and spectrum of services to discuss the programmatic and physical plant findings that were observed.

Note: during this formal meeting, the licensing specialist shall inform the licensee that the deadline to submit additional renewal documents is 5 business days after the scheduled Exit Conference.

11. If all requirements for the license are completed, including physical plant approval by the sanitarian, the licensing specialist shall submit a Renewal Licensing Packet to the licensing supervisor and the program manager for approval.

Note: final approval for receipt of a renewal license, suspension, revocation, and denial of a renewal license is granted by the deputy director for the Office of Planning, Policy, and Program Support (OPPPS).

12. Once approved, the Licensing Assistant shall ensure that the license is issued within 2 business days from the time of review and approval.

13. The license shall be valid for up to for 1 year.

Procedure D: Deficiencies Identified During License Renewals

Violations of the rules may be revealed during an inspection or an institutional abuse investigation. Whenever violations of rules are identified, the licensing specialist and/or sanitarian shall confer with the licensing supervisor and issue a ROF requiring the licensee to submit a CAP.

1. The licensing specialist and/or sanitarian may use his or her discretion in determining whether to issue a ROF.

a. If the provider responds appropriately without a ROF being issued, then there is no need for such enforcement.

b. If a pattern of non-compliance or health and safety concerns are evident, the ROF shall be issued to ensure compliance and to document the pattern and/or concerns.

2. The licensing specialist and/or sanitarian shall confer with the licensing supervisor to discuss all findings prior to issuing a ROF.



3. Once a ROF is issued, the licensee shall submit the completed CAP to the licensing specialist for approval in the timeframe indicated by the Licensing Specialist or Sanitarian in the ROF, but no later than ten (10) business days after receipt of the ROF.

4. The CAP shall include all deficiencies in detail, and list specific steps to prevent reoccurrence of the finding, a date of completion, and the person(s) responsible for ameliorating the deficiency.

5. The CAP shall be submitted to the licensing specialist’s supervisor for

review.

6. The licensing specialist, sanitarian, and supervisor shall discuss the CAP and determine if the facility’s actions appropriately address the findings.

7. Once the CAP is approved, a CAP approval letter is issued to the licensee. The letter includes notice of a subsequent unannounced site visit by the licensing specialist and/or sanitarian to verify CAP implementation.

8. The licensing specialist and/or sanitarian shall use the Corrective Action Plan Review Checklist tool during the unannounced inspection to verify implementation of a licensee’s CAP.

9. Once the corrections are verified and approved by the licensing Specialist and/or sanitarian, he or she shall submit his or her recommendations to the licensing supervisor. All corrections shall be verified in a timely manner. (If there are concerns, see Procedure E: Health and Safety Issues section as well as Provisional, Restricted, Suspended, and Revoked Licensure sections.)

10. If the CAP is not approved, the licensee may re-submit a revised CAP within 7 business days of receiving notice of the denial. A licensee shall be allowed 2 re-submissions. If the CAP is not approved, additional licensing actions may occur, such as issuing the licensee a placement restriction or a restricted license.

11. The management chain of command (including OPPPS’ program manager and deputy director) shall ultimately approve the granting of any license or an adverse licensing action.

12. Information gathered during the site inspection or record review may result in the need for an adverse licensing action. (See Provisional, Restricted, Suspended and Revoked Licensure sections.) If adverse licensing actions are being considered, OFL shall inform the appropriate deputies and administrators of affected CFSA administrations.



13. The deputy director for OPPPS must be consulted prior to the suspension or revocation of a license when youth reside in a licensed facility. (See Procedure E: Health and Safety Concerns below for more information.)

14. Recommendations to deny licensure shall be submitted to the deputy director for Program Operations for approval.

Procedure E: Health and Safety Concerns

If a health and safety issue at the facility is noted during the site inspection or record review, the licensing specialist or sanitarian shall notify the licensing supervisor or program manager.

1. The licensing supervisor in conjunction with the sanitarian and/or the licensing specialist, when appropriate, shall determine whether the youth are at imminent risk of illness or injury, or whether the condition may lead to a finding of child abuse and/or neglect under DC law.

2. If the person doing the inspection or record review believes that there is possible abuse and/or neglect of a youth, he or she shall make an immediate report to the CFSA Hotline. (See Procedure R: Institutional Investigation below for more information)

3. If it is determined that children may be at risk, the private agency’s chain of command shall immediately be notified so that appropriate action to protect the youth shall be initiated.

4. The licensing specialist or sanitarian (as appropriate) shall remain on site until either the health/safety risk has been ameliorated or other CFSA individuals have arrived to ensure the safety of the children.

Procedure F: License Modification

In some instances a licensee may desire to modify or change the terms of their license. CFSA may modify a license at any point during the licensing year upon request by the YRF or ILP, or on CFSA’s own authority, provided that the modification is not deleterious to the residents’ health, safety, or welfare.

1. A request for a modification made by a YRF or ILP shall be made to CFSA using the Request for Modification Form (Attachment G). The information contained in the request shall accomplish the following goals:

a. Set forth all relevant information concerning the specific modification sought, and the reason for seeking the modification.

b. Be accompanied by all relevant documentation and information. and

c. Include any additional information requested by CFSA.



2. CFSA shall review a request for a license modification and either grant or deny the request within 60 calendar days of receipt of the completed request.

3. Upon the licensing specialist’s receipt of all required documentation including a current approved Fire Inspection Report and Certificate of Occupancy (when required) a request for an Environmental and Sanitation Inspection will be submitted to the sanitarian.

4. The assigned sanitarian shall contact the licensee within 5 business days to coordinate a date and time to conduct an inspection of the facility.

5. The sanitarian shall discuss informally any findings with the licensee and assigned licensing specialist (if in attendance) at the site when he or she has completed the inspection.

6. Upon completion of the inspection, the sanitarian shall complete the ROF within 10 business days and submit it to the licensing supervisor for review.

7. The licensing specialist shall conduct a record review and staff or child interviews, as appropriate, to determine if the request comports with DCMR Chapter 62 and 63 and ensure that complying with the request will not have deleterious effect on any child served by the facility.

8. The licensing specialist and sanitarian shall submit his or her recommendations to the licensing supervisor for review.

9. After review and completion of all required documents, the licensing supervisor shall submit the recommendation to the program manager for review and approval.

10. OFL shall notify a licensee in writing of the decision to grant or deny a license modification through a Notice of Action (NOA) that includes the following information:

a. A statement of the grounds for the decision

b. An explanation of the right to and the method of requesting a fair hearing.

11. If OFL decides to grant the license modification, it shall issue the modified license within 2 business days of its decision.

12. All recommendations to deny a modification request shall be submitted to the deputy director for OPPPS for a final decision and signature within the 60 day timeframe required.

13. The licensee shall be notified within 2 business days after the final determination has been made to either grant or deny a Modification Request.



14. The licensee is required to submit a CAP (if necessary) within 10 business days of receipt of the ROF, outlining how deficiencies will be ameliorated, and be prevented from reoccurring.

Procedure G: Considerations for Facilities Located Outside the District of Columbia.

All facilities outside of the District of Columbia that service District of Columbia youth must possess a valid license to provide such a service to children from the appropriate licensing entity in the jurisdiction in which the facility is operating.

1. Although OFL does not license out-of-state facilities, an Environmental and Sanitation Inspection is required by OFL before youth can be placed in a facility outside the District of Columbia.

2. The licensee shall submit a Sanitation Inspection Request Letter (Attachment H) to OFL.

3. The licensee shall submit a Certificate of Occupancy and Fire Inspection (approved and current for each YRF and ILP location).

4. The sanitarian shall follow the timeframes and procedures outlined in the Procedure F: License Modification section listed above.

5. The licensee shall be issued an official letter with the decision to either grant or deny a facility for occupancy.

6. When necessary, the licensee is required to submit a CAP within 10 business days of receipt of the ROF outlining how deficiencies will be ameliorated, and be prevented from reoccurring.

7. OFL conducts an Environmental and Sanitation Inspection of out-of state facilities at least once a year

Note: CMPIA and OFL have the authority to request any information or supporting documentation that shall assist in the analysis and licensing decision making process as part of the process of determining whether to grant or deny a Modification. Requests to add an apartment or group home to an ILP or YRF license depends on safety checks, including ensuring that adequate staffing levels are maintained and that the required number of staff is cleared to work, based on regulatory requirements outlined in Chapters 62 & 63.



Procedure H: Handling Complaints and Allegations of Rule Violations

When a complaint is received, the licensing specialist or sanitarian shall obtain as much relevant information as possible from the complainant. The licensing specialist and/or sanitarian shall notify the licensing supervisor of the nature of the complaint and consult with him or her to determine the manner and time frame for which an investigation shall be conducted.

1. OFL shall conduct a full investigation of a complaint alleging a violation regarding 29 DCMR Chapters 62 or 63.

2. The licensing specialist shall investigate programmatic violations (i.e., violations of policy, rules and regulations). The sanitarian shall investigate concerns regarding the physical plant.

3. The licensing specialist and/or the sanitarian may inspect any facility licensed by CFSA at any time. Complaints may be made to OFL in writing, in person, by telephone, or electronically. The licensing specialist or sanitarian shall ensure that any actions taken as a result of the complaint and its resolution are documented.

Note: CFSA is authorized to contact other individuals or institutions in the course of acquiring information/data about the alleged incident.

4. If the complaint alleges child maltreatment (abuse or neglect), OFL staff shall notify the licensing supervisor immediately, and make a referral to CFSA’s Child Abuse and Neglect Hotline (202-671-SAFE.)

a. OFL staff shall advise the complainant to also make a report to the Hotline.

b. The licensing supervisor shall confirm whether the referral was accepted for an investigation. If the referral is accepted by CFSA’s Child Protective Services (CPS) administration, the following actions shall occur:

i. The licensing supervisor shall notify PSA and CMPIA of the allegation.

ii. No additional residents may be placed in the YRF or an ILP’s main facility during the investigation, unless CFSA authorizes the placement in writing.

iii. Upon the completion of a CPS investigation, the licensing specialist and/or sanitarian, as appropriate, shall conduct an inspection of the site, to ensure compliance with all regulations that were a subject of the compliant.

5. If the allegation is not accepted as an abuse or neglect report, the licensing specialist and/or sanitarian, as appropriate, shall investigate the allegation as a complaint.

a. The licensing specialist shall document that the complaint was shared with the appropriate jurisdiction and person contacted.



b. This information shall be included in the complaint file for the licensed facility.

6. If the complaint alleges rule violations, OFL staff shall obtain sufficient information to complete a full investigation and make a finding.

a. Complaints that allege rule violations may warrant an unannounced inspection from the licensing specialist.

b. The OFL staff may investigate a complaint by telephone with supervisory approval.

c. A complaint may be investigated by telephone only when the following circumstances apply:

i. The alleged non-compliance does not place children at risk of harm.

ii. The facility has not had numerous, repeated, or serious non-compliance.

iii. A monitoring visit has been made within the past 3 months during which substantial compliance has been documented.

d. The provider shall provide OFL with the necessary documentation to fully investigate the complaint, and make youth and staff available as necessary to determine the validity of the allegation.

e. All information obtained, and the issuance of any CAPs, shall be documented on a ROF. A copy shall be forwarded to the licensee by mail or email.

7. If the results of the investigation indicate that a violation has not occurred, the investigation is closed and all parties identified in the original report shall be notified in writing or electronically.

8. If the results of the investigation indicate that rule violations occurred, the findings shall be appropriately documented in a ROF, along with the necessary CAPs and forwarded to the provider.

Note: The steps for documentation of violations and time frames for CAPs are consistent with the process utilized during a licensing inspection unless there is an imminent risk to the children. If there is imminent risk to children, see Procedure E: Health and Safety Concerns for more information.

Procedure I: Suspension and Revocation of a License

The program manager shall provide to the licensee notice of suspension of licensure within 24 hours of the suspension.

1. OFL shall send a NOA, signed by the deputy director for OPPPS, detailing the reason for the suspension to the licensee within 1 business day of the action. The letter shall include notification of the licensee’s right to a Fair Hearing. (See Procedure M: Appeals of an Adverse Licensing Action for more information.)



2. A suspended license shall require that all children be immediately removed from a facility.

3. A license shall be suspended for 60 days. The suspension may be extended for an additional 60 days only if requested by the licensee and if OFL makes a determination that the licensee is making progress toward compliance with the relevant DCMR rule(s).

4. A facility with a suspended license must correct the health and/or safety issue(s) in order to have the license reinstated.

5. If the licensee becomes compliant within the specified timeframe, the licensing supervisor and the chain of command (including program manager and the deputy director) shall reinstate the license upon verification of compliance by the licensing specialist and or sanitarian.

6. If the facility does not achieve compliance within the timeframe of the suspension, the license shall be revoked. Revocation must be approved in advance by the deputy director for OPPPS.

7. A revocation may follow a suspension when a licensee fails to complete corrective action as required by CFSA.

Note: CFSA may revoke a license regardless of whether or not the license was previously suspended. Examples of a license being revoked without prior suspension include but are not limited to egregious negligence by a licensee, or numerous serious, hazardous conditions that threaten the life, health, and/or safety of youth.

8. If it is determined during an inspection that a serious health and safety issue constitutes a hazard to the youth placed in the facility, the license may be revoked with the recommendations of the licensing specialist and/or sanitarian, with the approval of the licensing supervisor, program manager, and deputy director.

9. A revoked license shall require that all children be removed from a facility immediately.

10. The deputy director for OPPPS shall sign an NOA regarding the revocation of a license. The NOA shall detail the reason for the revocation and shall be sent by the OFL to the licensee within 1 business day of the action. The NOA shall include notification to the licensee of its right to a Fair Hearing.

11. An entity that has a licensed revoked must apply for an original annual license in order to obtain another license.



Procedure J: Provisional Licenses

An original annual license or annual license renewal may be converted to a provisional license at any time due to non-compliance with 29 DCMR Chapters 62 or 63. A provisional license may be issued upon the recommendation of the licensing specialist, sanitarian, licensing supervisor and program manager when the private agency seeking licensure is not in full compliance with the DCMR. The program manager shall have final determination of whether the license is converted to a provisional license.

1. A provisional license shall be recommended for a facility when there has been ongoing non-compliance with a section of the rules that does not impact a youth’s health or safety. A provisional license shall also be recommended when a licensee has previously been cited and corrected an area of non-compliance and there is another finding of non-compliance within the same area.

2. A provisional license shall expire 90 days from the date it is issued and may include specific conditions, such as closed admissions, until certain requirements are met and compliance is achieved.

3. The issuance of a second provisional license may be recommended based upon evidence of progress of the licensed entity towards compliance.

4. An annual license or adverse licensing action, as appropriate, may also be recommended. If adverse licensing actions are being considered the OFL shall inform the appropriate deputies and administrators of affected CFSA administrations.

5. A second provisional license may be issued for up to 90 days. If the licensee fails to come into compliance within the timeframe of a second provisional license, a restricted license shall be issued.

6. A NOA regarding issuance of a provisional license shall be signed by the OFL program manager and must be sent by OFL to the licensed private agency within 1 business day of the decision to issue a provisional license. The NOA shall include notification of the right to a Fair Hearing.

Procedure K: Restricted Licenses

The restricted license serves as a formal notice to the licensee that it must achieve compliance with the rules within 90 days from the time of the restriction. A restricted license may be recommended when there are areas of non-compliance with the rules that can be ameliorated by placing conditions on the license, or when there are violations of rules that have continued to occur. A license shall not be restricted if the non-compliance constitutes a serious health or safety issue. If a license is restricted, the Placement Services Administration (PSA) shall not place any new children or youth in the facility, and the licensee shall not accept any new residents.



1. A recommendation to restrict a license shall be approved by the program manager and deputy director.

2. The licensing specialist shall prepare a Notice of Restricted Licensure detailing the reason for the restriction, within 2 business days of the action. A Notice of Restricted Licensure shall be signed by the program manager, and shall include notification of the right to a Fair Hearing.

3. Copies of the Notice of Restricted Licensure must be sent immediately to the licensee’s contracting agency within 2 business days of the action taken. If CFSA is the contracting agency, the program manager shall notify PSA, CMPIA, and CPA.

4. A restricted license shall expire in no more than 90 days and may not be renewed.

Procedure L: Appeals of an Adverse Licensing Action

When an applicant or licensee of a YRF or an ILP’s application or license is to be denied, or modified, suspended, converted, or revoked, OFL shall send written notice of the decision through an NOA within 1 business day from the time the decision is made.

1. The NOA shall inform the applicant or licensee of the particular deficiencies preventing the licensure and provide guidance for corrective action(s), including the time, place and issues involved.

2. An applicant or licensee may appeal any adverse licensing action, within 30 days of receipt of the notice informing the licensee or applicant of the adverse action.

3. All appeals regarding an adverse licensing decision against a YRF or ILP are heard through the DC Office of Administrative Hearings (OAH). OFL staff shall direct an applicant or licensee wishing to appeal to contact OAH:

DC Office of Administrative Hearings 825 North Capitol Street, NE Suite 4150 Washington, DC 20002-4210 (202) 442-9097, phone (202) 442-4789, fax

4. A licensing specialist and/or sanitarian will confer with his/her supervisor and program manager whenever there is an appeal of adverse licensing action.

5. The licensing specialist and/or sanitarian and the licensing supervisor shall attend any appeal hearing as a witness for CFSA.



Procedure M: Variances

In order to receive a variance, an applicant or licensee shall complete and submit a Request for Variance Form for a YRF or ILP to OFL. Documentation shall be sufficient to establish that the facility’s procedures comply with the intent of 29 DCMR Chapters 62 and 63.

1. Upon receipt of the variance, the licensing specialist shall review the request and notify the applicant or licensee if any additional documentation is needed.

2. If the request for variance does not support the applicant’s or licensee’s request, the request shall be denied.

3. If the variance pertains to programmatic requirements, it shall be reviewed by the licensing specialist. If the variance request concerns a physical plant requirement it will be reviewed by the sanitarian. Either party, as appropriate, shall complete a site inspection, record review, and /or staff or child interviews, to determine if the variance request conforms to regulations and is not contrary to the youth’s safety and/or well-being.

4. Upon evaluation of the request, the licensing specialist or sanitarian shall submit his or her recommendation to the appropriate chain of command.

5. Within 2 days of the decision, the licensing specialist shall send the applicant or licensee an NOA detailing the outcome of its request and the reasons for the decision. The notice shall also inform the applicant or licensee of its right to a Fair Hearing if aggrieved by the decision.

6. A variance shall remain in effect for the duration of the current licensing period. A licensee shall resubmit a request for the same variance during the annual renewal process.

7. If the request for a variance corresponds with the licensing period for an original annual license or annual license renewal, the decision regarding the variance will be made in concert with the overall licensing decision.

Procedure N: Unusual Incidents

All unusual incidents concerning violations of 29 DCMR Chapters 62 or 63, or allegations of child abuse or neglect shall be reported immediately on an Unusual Incident Report Form, and submitted to OFL within 24 hours of occurrence. Information provided on the form shall identify the individuals involved and/or witnessing the incident; and address the location of incident; type of incident; intervention(s) used to resolve the incident and includes a brief description of the incident.

1. Licensees shall submit copies of Unusual Incident Reports (UI) to the licensing assistant in OFL.



2. The licensing specialist assigned to a licensee shall review each UI that alleges a rule violation or child abuse or neglect. The frequency and manner of reviewing the unusual incidents shall be established by the OPPPS program manager.

3. If a violation of rules is alleged, the licensing specialist shall conduct an investigation prior to issuing a deficiency. (See Procedure H: Handling Complaints and Allegations of Rule Violations above for more information)

4. If child abuse or neglect is alleged, the licensing specialist shall follow the procedures outlined in Procedure P: Institutional Investigations below.

5. If serious health or safety issues remain, the licensing specialist shall immediately notify the chain of command in accordance with Procedure E: Health and Safety Concerns. If the provider has violated one or more rules, a ROF shall be issued and the provider shall be required to submit a corrective action plan.

Procedure O: Institutional Investigations

Allegations of child abuse or neglect shall be reported to the CFSA Hotline. OFL receives notification of allegations of child abuse or neglect through a Critical Event Form issued electronically by the CFSA Hotline. When a complaint against a facility is accepted for investigation by CPS, the Institutional Investigations Unit is responsible for completion of the investigation. The licensing specialist and/or sanitarian shall confer with the investigator, and respond to requests for assistance or information as appropriate.

Note: CFSA staff members are mandated reporters and required to contact the CFSA Hotline whenever acts of child abuse or neglect are suspected.

1. Upon notification of an institutional investigation, the licensing supervisor shall notify via e-mail PSA, CMPIA, CPA, or the contracting agency, that the facility is closed for placement pending the outcome of the investigation. The chain of command in OFL shall be copied in the e-mail.

2. The licensing supervisor shall also notify the licensed facility in writing on the day of notification of an investigation, and direct that the staff named (if applicable) in the allegation be placed on administrative leave or reassigned so that they are not working directly with children until the investigation is complete.

Note: ILPs that operate residential units may remain open at the discretion of CFSA. Main facility ILP and YRF locations shall be closed to admissions until the investigation is complete. The licensing specialist shall confer with the licensing supervisor regarding a decision to close admission to an ILP.



3. When appropriate, during the investigation the licensing specialist or sanitarian shall confer with staff from CFSA’s Institutional Investigations Unit in the development of a safety plan for youth residing in the facility, and shall visit the facility to verify the safety of any youth remaining at the facility.

Note: frequency of visits by OFL shall be based on the severity of the allegations, whether youth remain in the facility and whether there are outstanding licensing issues to be rectified.

4. When directed by the licensing supervisor, the licensing specialist or sanitarian shall complete an investigation to determine if there is a violation of rules in accordance with the procedure H: Handling Complaints and Allegations of Rule Violations.

5. If serious health or safety issues remain, the licensing specialist or sanitarian shall notify the chain of command. The licensing supervisor and his or her chain of command may convert an original annual or annual license renewal to a provisional, restricted, or suspended license or may revoke the license when warranted.

6. Within 5 days of receipt of the result of the child abuse or neglect investigation, the licensing specialist or sanitarian shall complete a narrative investigation report describing his/her findings and recommendations for any rule violations identified during the investigation, according to the procedures outlined in Procedure H: Handling Complaints and Allegations of Rule Violations above for more information. The investigation narrative report shall be submitted to the licensing supervisor for review and approval. The licensing supervisor shall submit the report and recommendations to the program manager for approval.

Note: If adverse licensing actions are being considered, OFL shall inform the appropriate deputies and administrators of affected CFSA administrations, i.e., OPPPS, CPA, CMPIA, and PSA. Depending on the nature of the findings, OFL shall formulate a plan of action in collaboration with the other affected administrations.

7. The licensing supervisor shall ensure the receipt of written notification of the results of the investigation from the CPS unit.

a. The licensing supervisor shall issue notification to the licensee regarding the outcome of the investigation, status of placement admissions and/or any additional licensing actions required within 1 business day from receipt of notice.

b. If the investigation is unfounded and no safety or licensing issues remain, the licensing supervisor shall notify PSA and the appropriate contracting agency that the facility is able to receive children.

Program – Facility Licensing Policy Attachment A: Definitions Page 1 of 2

Definitions Annual License - Permission granted to an applicant to operate an independent living program under chapter 62 or 63 of the DCMR.

Corrective Action Plan (CAP) – A plan developed by the applicant or licensee to ameliorate all deficiencies (findings that are out of compliance with the regulations) identified on the Report of Findings. The CAP responses must describe how the findings will be corrected and prevented from reoccurring.

Converted License - A license changed from an annual license to a provisional or restricted license when an immediate or serious and continuing danger to the health, safety, or welfare of the residents of the facility exits. If the licensee comes into compliance with the regulatory requirements an annual license can be reinstated.

Deficiencies – Areas of non-compliance with the regulations outlined in the DCMR Chapters 62 or 63.

Entrance Conference - A meeting held with the applicant/licensee to describe the on-site licensing activity to be conducted and the anticipated timeframes that OFL staff would be at the facility.

Environmental and Sanitation Inspection Checklist – Tool based on regulatory requirements outlined in Title 29 DCMR Chapters 62 and 63 that the sanitarian uses to conduct physical plant inspections of all facilities where District of Columbia youth are placed.

Final Walk-Through - The final inspection of an applicant’s facility, conducted by the sanitarian and licensing specialist to ensure that additional changes have not occurred from the previous inspection and that the facility is prepared to accept admissions.

Independent Living Program (ILP) – A residential program for persons who (1) are 16 – 21 years of age, (2) have sufficient maturity to live without regular and continuous supervision and monitoring, (3) reside in apartments, and (4) are provided with monitoring and services that reflect and support the person’s ability to reside in the community without regular and continuous supervision and monitoring.

Licensing Specialist – An OFL staff person is responsible for ensuring compliance with the programmatic areas of the Youth Residential Facility and Independent Living Program regulations.

Main Facility - The central independent living program edifice provides on-site staff supervision and has more than one resident.

Notice of Action (NOA) – Official notification issued to a licensee regarding any licensing actions taken by the Office of Facility Licensing (e.g., issuance of an annual, provisional or restricted license).

Notice of Application Status (NAS) – Official notification issued to an applicant regarding the status of their application to operate a Youth Residential Facility or and Independent Living Program.

Original Annual License – The initial license that is granted to an applicant whose program, facilities, and operations are in full compliance with the regulatory standards outlined in Chapters 62 and/or 63 of Title 29 DCMR.

Partnership Meeting - A meeting held when an Original Annual License is issued to a new licensee. Discussion includes requirements to maintain a license. When appropriate, staff from CMPIA, CPA, and PSA will attend.

Program – Facility Licensing Policy Attachment A: Definitions Page 2 of 2

Physical Plant Inspection – A Sanitation and Environmental Inspection conducted by a sanitarian at all facilities operated by an applicant or licensee.

Provisional License - A license issued in instances where the applicant is temporarily unable to comply with all of the requirements of Chapter 62 or 63 of the DCMR. The license is conditioned upon whether the requirements will be met within a specific length of time.

Report of Findings (ROF) – An official report issued to an applicant/licensee of the findings observed/found during on-site physical plant inspections, staff and resident record reviews and interviews conducted by the licensing specialist and/or sanitarian.

Restricted License – A license that is issued to an ILP or YRF that is not in compliance with regulations found in DCMR 62 or 63. It prohibits the ILP or YRF from accepting new residents or providing certain specified services that it otherwise would be authorized to provide.

Sanitarian – The Office of Facility Licensing staff person responsible for conducting sanitation and environmental inspections to ensure the facility meets the safety and regulatory requirements outlined in Chapters 62 and 63 of Title 29 DCMR.

Sanitation and Environmental On-Site Inspection – A physical plant inspection of a facility conducted by a sanitarian to ensure compliance with regulatory requirements outlined in Chapters 62 and 63 of Title 29 DCMR.

Suspended License – A license suspended for a period of no longer than 60 days as a result of non-compliance with regulatory standards. All residents must be immediately removed from a facility when a license is suspended.

Variance- Permission by OFL for an ILP or YRF to deviate from a requirement of DCMR Chapter 62 or 63.

Youth Residential Facility* (YRF) - A residential placement providing adult supervision and care for one or more children who are not related by blood, marriage, guardianship, or adoption (including both final and non-final adoptive placements) to any of the facility’s adult caregivers and who were found to be in need of a specialized living arrangements as result of one or more of the following circumstances:

a) A detention or shelter care hearing held pursuant to D.C. Code § 16-2312 b) A dispositional hearing held pursuant to D.C. Code § 16-2317 c) Family crisis, homelessness, runaway status, or other circumstances creating a need for out-

of-home supervision and care d) A mental or physical disability that requires, in accordance with 20 U.S.C. § 1401, et seq.,

more services than can be provided by nonresidential programs.

* For purposes of this policy, the term “youth residential facility” only includes youth shelters, runaway shelters, emergency care facilities, and youth group homes.